Latest posts by Geoff Bathje, Ph.D. (see all)
- Combining Psychedelics with Capitalism May Cause Unintended Side Effects - January 24, 2019
- It’s Time for the Psychedelic Renaissance to Join the Harm Reduction Movement - October 29, 2018
- Psychedelic-Assisted Therapy During Prohibition - March 21, 2018
Latest posts by Vilmarie Fraguada Narloch, PsyD (see all)
Latest posts by Joseph Rhea, JD, Ph.D. (see all)
There has been a boom in interest in psychedelics, though many people, including licensed providers (LPs), are unfamiliar with the applicable laws and gray areas. Supports, safety nets, and drug knowledge still need to be expanded for those who use psychedelics, while the critical analysis of where psychedelics fit into the broader War on Drugs often seems lacking or under appreciated. As clinical research on psychedelics as medicines has progressed and awareness of their therapeutic potential has risen, LPs must decide how best to support their clients who use these substances. This includes discussion of the role of harm reduction and “integration” in relation to psychedelics, along with possible legal and ethical considerations for LPs in providing these services. At the same time, LPs, researchers, and advocates must grapple with how to address psychedelics in a way that does not reinforce the harms and injustices of the War on Drugs. We believe the harm reduction movement has much to offer to those who are interested in the current “Psychedelic Renaissance.”
The Harm Reduction Movement
Thus, harm reduction includes not just reducing risks of drug use, but engaging in policy work, community organizing, and activism to reduce stigma and harmful drug policies
Harm Reduction is a well-established approach to reducing the negative consequences associated with drug use. It is also a social justice movement, rooted in respecting the rights and humanity of people who use drugs. Thus, harm reduction includes not just reducing risks of drug use, but engaging in policy work, community organizing, and activism to reduce stigma and harmful drug policies. The harm reduction movement dates back to the 1920s in the U.K. with the Rolleston Report Committee recognizing that drug use need not be criminalized, and to 1940 in Mexico, when legislation allowed doctors to prescribe drugs to people with addictions and removed criminal penalties for possession. In the U.S., harm reduction practices surged in response to the AIDS epidemic, leading to the development of grassroots movements such as the Gay Men’s Health Crisis, Act Up, and Stop AIDS.
Essentially, harm reduction emerged from these communities not being well served by traditional health care, who took matters into their own hands. This tradition continued as syringe exchange and naloxone dispensing programs were propagated by people who use drugs and their allies, often initially operating illegally or in the gray areas of the law to save lives and protect health. This level of policy work to identify and navigate the gray areas in the law is not well suited for the average individual licensed practitioner (LP), but instead tends to emerge out of collective efforts to find creative ways to provide resources and services while averting criminalization.
This approach to therapy maintains the original spirit of harm reduction in recognizing that even small behavioral changes, such as not sharing syringes, can reduce or even eliminate certain risks, such as HIV transmission. As such, this approach involves supporting clients in making “any positive change,” as they define it for themselves
The work of the late Alan Marlatt and colleagues from the University of Washington, Patt Denning and Jeannie Little at the Center for Harm Reduction Therapy in San Francisco, and Andrew Tatarsky and colleagues at the Center for Optimal Living in New York City, and others have further extended harm reduction into therapy settings, and provided a theoretical basis for the practice of harm reduction psychotherapy. This approach to therapy maintains the original spirit of harm reduction in recognizing that even small behavioral changes, such as not sharing syringes, can reduce or even eliminate certain risks, such as HIV transmission. As such, this approach involves supporting clients in making “any positive change,” as they define it for themselves.
Psychedelic Harm Reduction
Historically, the psychedelic and harm reduction movements have not overlapped significantly. However, we believe the sociopolitical lens and praxis provided by the harm reduction movement is very relevant to the current “Psychedelic Renaissance”
Historically, the psychedelic and harm reduction movements have not overlapped significantly. However, we believe the sociopolitical lens and praxis provided by the harm reduction movement is very relevant to the current “Psychedelic Renaissance”. For example, the most visible and powerful figures in psychedelics are disproportionately highly educated or wealthy white men. What are the consequences of such a homogenous group making most of the decisions and holding most of the power? Should it be surprising that we have seen increasingly frequent criticism of inequality, power, lack of diversity, and lack of systemic critique in psychedelics? From a harm reduction perspective, those most at risk and most in need should hold power and receive the most attention. People who use drugs often form their own organizations or are sought out for prominent roles in harm reduction, such as community organizers, program developers, outreach workers, or board members.
Beyond these systemic issues, it is often said that negative attention resulting from risky psychedelic-related incidents in the 1960s was used to discredit research and implement prohibitionist policies. Proponents of the War on Drugs will always seek to stigmatize use and publicize the most negative experiences to denounce and impede progress toward liberalizing drug policy. Harm reduction provides an approach to drug use and drug policy that can help prevent similar outcomes with psychedelics in the current era.
Despite the hesitation of some within the psychedelic community to acknowledge the risks inherent in the use of psychedelics or to draw parallels between medicinal and personal use, there are perils to psychedelic exceptionalism (viewing psychedelics as inherently superior to other substances, or deserving of special legal protection). For example, exceptionalism can lead to the stigmatizing of other drugs or people who use them by negative comparison, advocating for only psychedelics while neglecting those most oppressed by the War on Drugs, discounting that almost any drug has medicinal uses and that much drug use is for symptom relief, or neglecting that various cultures have considered a range of drugs to be sacred (e.g., tobacco, wine, opium, coca, cannabis, etc.). Still, harm reduction efforts for psychedelics have proliferated in recent years. Organizations such as the Zendo Project, DanceSafe, Bunk Police, Energy Control, Students for Sensible Drug Policy, and others provide much needed peer support, drug education, and other harm reduction services (drug checking, safer use materials, etc.). However, many of these efforts have focused more on events where psychedelics are consumed than on individuals using in more private settings, the broader social justice goals of the harm reduction movement, or on LP’s providing harm reduction in individual or group therapy settings.
Licensed Practitioners in Harm Reduction
There are several instances where harm reduction may be relevant to LPs working with clients. While being overly conservative would inhibit much harm reduction work, all professional ethical codes emphasize the necessity of competence in practicing any approach, so LPs should seek appropriate training and familiarize themselves with the above references (and the first author’s previous article) if they intend to provide harm reduction services to people who use drugs.
An important role for LPs providing harm reduction therapy involves helping individuals identify and prevent potential harms associated with their use of drugs, with a focus on “drug, set, and setting.” For our purposes, we can broadly define “set” as things about the individual (such as mood, personality, personal identity, health status, etc.) and “setting” as things in the person’s environment (the social and cultural context). People of course also need accurate information about the drugs they use, including their effects and impact of the dose size, and how to reduce the unique risks associated with each drug.
Harm reduction can include a range of other activities, such as explaining about testing drugs for impurities (though cautioning clients is warranted in states where drug testing kits are considered to be paraphernalia), explaining laws related to drug use and paraphernalia, and encouraging safer practices for use. This work requires the therapist to have a broad knowledge of various drugs and their use. Multiple resources can be found for each drug, such as the Harm Reduction Coalition’s “H is for Heroin” and related guides, or Students for Sensible Drug Policy’s “Just Say Know” program, which covers DMT, ketamine, LSD, psilocybin, and cannabis, among other drugs. While we cannot fully vouch for the accuracy of every guide, these guides are generally valuable for LP’s and people who use drugs.
As LPs explore psychedelic harm reduction with clients, they should be aware of the limits of First Amendment protection. In Conant v. Walters (2002), the Ninth Circuit Court of Appeals examined the situation of California doctors recommending cannabis to their patients. The Court found that those recommendations were protected from federal action (DEA licensing revocation and federal investigation) because California doctors were not prescribing cannabis or in any other way directly involved in providing cannabis. There is thus a line between free speech and discussion (which courts are very reluctant to restrict) and actions, such as providing contacts for the procurement of a controlled substance or holding a space open for the use of a controlled substance. These latter activities expose LPs to criminal prosecution for conspiracy. At the state level, we are unaware of any licensing actions based on an LP engaging in discussion with a client about the client’s use of psychedelics.
When clients express an intention to consume a psychedelic or other drug, LP’s are not required to dissuade them from doing so. In fact, within the harm reduction approach, such attempts to control behavior are seen as unhelpful judgments that can produce stigma and shame, make it difficult for clients to be honest, create resistance that might increase risky behavior, weaken the therapeutic relationship, and increase the odds of clients terminating therapy. When a client expresses they are using or intend to use a drug, harm reduction-oriented LPs will tend to 1) seek to understand the function of the drug for the client (What does it do for them? What do they get out of it?), 2) affirm the client’s autonomy to make that choice, so as not to promote resistance in the relationship, 3) practice radical acceptance and refrain from judgment of the behavior, 4) ask clients if they are aware of the risks of their drug use and how to protect themselves (offering accurate information if the client is receptive), 5) ask the client whether they dislike or are seeking to change their substance use in any way, while respecting their goals, and 6) offer, but not require, other approaches to achieve the same goals the client hopes to achieve by using drugs (e.g., offer trauma therapy to address flashbacks that the client manages with heroin).
Where Do Psychedelic “Integration” and “Preparation” Fit in with Harm Reduction?
Some in the field are reluctant to support harm reduction and integration services, which seems to be related to confusion about the scope and definition of each. Each term has been used to denote a range of LP conduct: from recommending psychedelics to clients (clearly illegal outside of sanctioned uses, such as clinical trials or ketamine clinics) to merely counseling people who have independently chosen to use a psychedelic (clearly legal).
We define “integration” as the processing one provides after a psychedelic experience. This typically involves discussing and internalizing experiences a person believes were beneficial to them (e.g., a sense of reconnecting with oneself or the lifting of one’s depression) that were negative (e.g., a “bad trip”) or that they have not yet been able to interpret (e.g., what did a particular part of their experience mean?). “Harm reduction,” on the other hand, mostly refers to things done prior to a person’s ongoing next use of a drug, such discussing a person’s pattern of use and providing information intended to reduce risks (e.g., encouraging them not to use while driving or in other high-risk situations, discussing the impact of set and setting, etc.). Warning someone about the dangers of a behavior is unlikely to ever be considered legally or ethically problematic.
Harm reduction and integration overlap with regard to reducing the harm or ongoing risks of difficult or negative experiences with psychedelics (e.g., helping someone through heightened anxiety or suicidal ideation stemming from a difficult psychedelic experience). Harm reduction and integration can be further differentiated from “preparation” for therapeutic experiences. In preparation, LPs who do not provide the drug or a physical location for its use represent that their professional services can (in advance of use) make an illegal drug experience therapeutic. The risk here is that if an LP becomes a material accessory to the drug experience during preparation, a client could potentially claim the only reason they followed through with the use of an illegal drug was because of the involvement of the LP. In that case, a licensing board may determine the LP made themselves into an integral part of the illegal experience under the guise of providing professional services (and violating duty of care). In summary, LPs face greater risk when doing preparation work versus post experience integration, particularly when the provider is recommending (or is perceived as recommending) the psychedelic experience as a therapeutic activity as opposed to focusing on preventing harm.
Some have warned of the legal risks of integration work based on it being “new” or unestablished. But, despite the diversity of techniques that are described as integration, from being in nature to journaling, art, or therapy, the concept is not new in psychology. The earliest reference to integration in psychology may be Pierre Janet’s definition in 1889 of traumatization as a “failure of integrative capacity,” with the major goal of therapy being restoration of the ability to integrate experiences. Further, the integration of insights derived from therapy has always been implicit in psychoanalysis, if only through sheer repetition and time spent in therapy. As briefer models of therapy were developed, most theorists took for granted that clients would retain things they worked through in therapy. As a result, relapse rates for most conditions are exceedingly high. Of course, even in brief therapy, therapists often recognize that much of the work of therapy occurs between sessions and supplement client processing and integration by recommending self-help literature and “homework” to be done between appointments. Further, some theories of psychotherapy have explicitly put a major focus on integration (see Sensorimotor Therapy, also known as Sensorimotor Processing and Integration). It is false to claim that integration is a new and untested approach, as the concept of integration is ubiquitous throughout different schools of psychotherapy, even if described in different terms.
Calling for More Harm Reduction
harm reductionists are often guided by their conscience in feeling an obligation not to deny people therapy just because they have consumed drugs that are currently illegal, especially when they believe these laws exist to reinforce classism and racism
The American Psychological Association’s ethical guidelines and the guidelines of many other LPs support practice based on a range of evidence, following one’s conscience, and prioritizing the well-being of clients. According to the APA, “Psychologists may consider other materials and guidelines that have been adopted or endorsed by scientific and professional psychological organizations and the dictates of their own conscience, as well as consult with others within the field.” Of particular note is that harm reductionists are often guided by their conscience in feeling an obligation not to deny people therapy just because they have consumed drugs that are currently illegal, especially when they believe these laws exist to reinforce classism and racism. Certainly, there is no legal or ethical requirement to turn such clients away, or deny them the opportunity to process their experiences with drug use, regardless of whether they see their drug use as beneficial, problematic, or neutral.
In conclusion, it is not only appropriate, but essential, for LP’s to learn about and engage in harm reduction related to psychedelic drugs if we wish to protect our clients and remain part of the broader justice movement against the War on Drugs. We would be naïve to think everyone who is struggling with depression, trauma, addiction, and other intractable issues will wait years for medical approval of psychedelics before trying them on their own. The positive publicity around the therapeutic potential of psychedelics is already causing many people to seek out experiences they hope will be healing. Of course, harm reduction is not only for LP’s. People who use drugs and their allies have always been at the forefront of harm reduction, and it is important that they continue to be so. We call on LPs who are interested in psychedelics as medicines to join and learn from the broader harm reduction movement.